Treatment Options for Alcohol Use Disorder Acamprosate Naltrexone Disulfiram Topiramate Pearls Pearls Alcohol Withdrawal Syndrome Na+ glu Pearls mu opiates Pearls Ca+ CAI Serves as “artif icial alcohol”; may Can be used f or patients who Disulf iram should not be given to May be usef ul f or patients who be less ef f ective in situations in have achieved abstinence, are a patient in a state of alcohol have achieved abstinence, are glu GABA which the patient has not yet Alcohol either acts directly upon mu trying to achieve abstinence, or intoxication or without the GABA trying to achieve abstinence, or abstained; patients should are trying to reduce heavy Alcohol is metabolized to acetaldehyde, patient’s f ull knowledge; the are trying to reduce heavy Symptoms begin within a f ew hours of discontinuation and may Acamprosate is a derivative of the opioid receptors or causes release of continue treatment even if relapse drinking; less ef f ective in patients which in turn is metabolized by patient should not take disulf iram Like alcohol, topiramate both reduces drinking; may be usef ul as an last a f ew days to a week amino acid taurine and, like alcohol, endogenous opioids; in either case, the occurs but should disclose any who are not abstinent at the time aldehyde dehydrogenase. Disulf iram is f or at least 12 hours af ter drinking; excitatory glutamate adjunct agent; side ef f ects both reduces excitatory glutamate result is increased dopamine release new drinking; dosing schedule of treatment initiation; adherence an irreversible inhibitor of aldehyde a reaction may occur f or up to 2 neurotransmission and enhances include sedation, nausea, and neurotransmission and enhances to the nucleus accumbens. Naltrexone may af f ect adherence; generally is greatly increased with the dehydrogenase, thereby blocking this weeks af ter disulf iram is stopped; inhibitory GABA neurotransmission. It weight loss; can cause metabolic Outpatient Treatment inhibitory GABA neurotransmission. In blocks mu opioid receptors, and thus well tolerated, with diarrhea as the injectable f ormulation; side second-stage metabolism. When the patient should be advised not is also a carbonic anhydrase inhibitor. acidosis or kidney stones; particular, it seems to block mGlu theoretically reduces the euphoria and most common side ef f ect; no ef f ects include nausea, vomiting, alcohol is consumed in a patient taking to consume any f ood or adverse ef f ects may be dose For patients with: receptors and perhaps also NMDA high of drinking. known interactions with and site reactions (injection); may disulf iram, toxic levels of acetaldehyde beverages containing alcohol; the dependent Mild to moderate AWS (tremor, elevated pulse rate and blood receptors. build up, which leads to f lushing, 90 #4799090 pressure, sweating, agitation, nervousness, sleeplessness, be pref erred treatment if goal is 90 psychotropic medications (not #479#400098 patient should carry an so 098 dr so and e here dr so and #4799090 #400 d sohere nametc hospital name ital so anhospaddress address etchere Dosing and Use me 8 dr sol nass etc 4e9039o 09 4e9039o spitadre etc o etc #400 ho ad 9039 name etc etc 4e address tachycardia, nausea, vomiting, and anxiety, and depression) etc name ss etc addre metabolized by hepatic enzymes; reduced-risk drinking; can block e namress emergency card stating that s/he add 90 #4799090 90 #479#400098 so 098 dr so and e here dr so and #4799090 other symptoms. #400 d sohere nametc hospital name ital so anhospaddress Dosing and Use address etchere 8 sol name etc 39o 09 dr itadress o 4e90 etc does not inhibit/induce hepatic ef f ects of opioid-containing 4e9039o etc #400 hospad 9039 name etc etc is taking disulf iram; common side 4e address etc name ss etc addre e namress add #479#400098 098 dr so name here dr so and #400 d sohereress etc hospital name ital and 90 90 #4799090 so so #4799090 enzymes) medications; some patients ef f ects include metallic taste, Formulations: Consists of : Dosing and Use Relief of immediate symptoms, prevention of complications, anhospadd address etchere 8 sol name etc 39o 09 dr itadress o 4e90 etc 4e9039o etc complain of apathy with chronic #400 hospad 9039 name etc etc 4e Formulations: dermatitis, and sedation; not Tablets: 25 mg, 100 mg, 200 mg address etc name ss etc addre e namress add and initiation of rehabilitation 90 #4799090 90 treatment #479#400098 Sprinkle capsule: 15 mg, 25 mg so Tablets: 25 mg, 50 mg, 100 mg recommended f or patients older 098 dr so name here dr so and and #4799090 #400 d sohereress etc hospital name so Dosing and Use ital anhosp me add address etchere 8 dr sol nass etc 4e9039o 09 spitadre 4e9039o etc o etc #400 ho ad 9039 name etc etc 4e address etc Supportive care and repletion of nutrient, f luid, or mineral name ss etc addre e namress than age 60 or f or those with add Formulations: Oral solution: 12 mg/0.6 mL Intramuscular: 380 mg/vial severe pulmonary disease, def iciencies (especially vitamin B) Tablet: 333 mg Dosage Range: Formulations: chronic renal f ailure, diabetes, Benzodiazepines Up to 300 mg/day; requires slow Dosage Range: Tablet: 250 mg, 500 mg Alternative options may include carbamazepine, valproate, or Dosage Range: peripheral neuropathy, seizures, upward titration to reduce side ef f ects Oral: 50 mg/day topiramate 666 mg 3 times daily (>60 kg) Special Populations cirrhosis, or portal hypertension Injection: 380 mg every 4 weeks Special Populations Dosage Range: Special Populations 666 mg 2 times daily (<60 kg) Approved For: Approved For: 250–500 mg/day, one-year duration Multiple seizure disorders; migraine Saf ety and ef f icacy have not Alcohol dependence prophylaxis Inpatient Treatment Saf ety and ef f icacy have not Special Populations Approved f or use in children age been established Blockade of effects of exogenously Approved For: Not approved f or alcohol use disorder Approved For: been established Maintenance of alcohol 2 and older f or treatment of For patients with: administered opioids (oral only) Maintenance of alcohol Pregnancy risk category C (some abstinence Saf ety and ef f icacy have not seizures; clearance is increased Severe AWS (hallucinations, delirium tremens, psychotic abstinence animal studies show adverse Pregnancy risk category C (some been established in pediatric patients symptoms, and seizures) ef f ects; no controlled studies in Side Effects and Safety animal studies show adverse Side Effects and Safety Extremely high alcohol intake humans) ef f ects; no controlled studies in Side Effects and Safety Signif icant psychiatric symptoms Pregnancy risk category C (some Pregnancy risk category C (some humans) Side Effects and Safety animal studies show adverse animal studies show adverse ef f ects; no controlled studies in ef f ects; no controlled studies in Limited available data in patients Limited available data in patients humans) humans) with cardiac impairment with cardiac impairment Dose adjustment not generally For moderate renal impairment, Eosinophilic pneumonia, necessary f or mild renal Contraindicated in patients with severe cardiovascular disease Use with caution in patients with cardiac impairment Psychosocial + Pharmacologic hepatocellular injury (at excessive impairment; not studied in recommended dose is 333 mg doses), severe injection site moderate to severe impairment Metabolic acidosis, kidney stones, three times daily; Myocardial inf arction, congestive Lower dose by half f or patients reactions requiring surgery secondary narrow-angle closure contraindicated in severe heart f ailure, respiratory Not recommended f or patients with renal impairment Dose adjustment not generally glaucoma, oligohidrosis and impairment Do not use if patient: is taking depression, hepatotoxicity with chronic renal f ailure necessary f or mild hepatic hyperthermia (more common in Suicidal ideation and behavior opioid analgesics, is currently impairment; not studied in severe Contraindicated in patients taking children), rare activation of suicidal Use with caution in patients with dependent on opioids or is in hepatic impairment; ideation and behavior Dose adjustment not generally metronidazole, amprenavir, Not recommended f or patients hepatic impairment acute opiate withdrawal, has contraindicated in acute hepatitis necessary f or patients with ritonavir, or sertraline, and in with hepatic insuf f iciency or Do not use if patient has severe f ailed the naloxone challenge, or or liver f ailure those with psychosis or No absolute contraindications renal impairment hepatic impairment has a positive urine screen f or cirrhosis cardiovascular disease other than allergy to topiramate opioids Pharmacotherapy is good f or: Patients with active alcohol dependence Patients who have stopped drinking but have cravings or slips Patients who have previously f ailed to respond to psychosocial Motivational Enhancement Therapy Cognitive Behavioral Therapy 12-Step Facilitation and 12-Step Fellowships approaches Psychotherapeutic or psychosocial approaches can: Motivational interviewing is patient-f ocused Twelve-Step Facilitation (TSF) consists of a structured, counseling with the direct goal of enhancing one’s manual-driven approach to f acilitating early recovery f rom Increase motivation f or abstinence motivation to change by helping explore and alcohol abuse/alcoholism and other drug abuse/addiction. Improve motivation f or medication adherence resolve ambivalence (e.g., “I want to stop drinking, Cognitive behavioral therapy (CBT) is based on the Its purpose is to help patients accept their need to abstain Improve overall outcomes but I’m af raid I’ll be awkward in social situations”). premise that our behaviors stem f rom our thoughts and to actively participate in 12-step f ellowships (such as 25 Although it was originally developed to help Joe’s Alcoholics Anonymous, or AA) as a means of maintaining Bar and belief s, and theref ore that negative thoughts 0 25 0 individuals with problem drinking, it can be used in can lead to maladaptive behavior. CBT is abstinence. It is intended to be implemented on an the treatment of patients with other f orms of designed to modify the behaviors and individual basis in 12 to 15 sessions and is based in the 12 substance abuse and dependence. With thoughts/belief s that contribute to substance abuse steps and traditions of AA. motivational interviewing the clinician is a f acilitator, and dependence. CBT helps patients identif y helping the patient identif y, articulate, and resolve triggers f or substance use, such as particular Although mutual support groups such as 12-step his or her own ambivalence without direct people or places or even emotions, and helps them f ellowships can be very benef icial in helping patients with persuasion, conf rontation, or coercion. develop techniques to avoid those triggers or, if substance use disorder, these programs are based on the unavoidable, to cope with them. premise that addiction is an illness in which those af f licted Motivational enhancement therapy (MET) is an are unable to control their use of the drug. As such, they adaptation of motivational interviewing in which the typically require complete abstinence as the goal. This may therapist uses f eedback to strengthen the patient’s theref ore pose conf lict f or patients with alcohol use own motivation and commitment to change. disorder who are attempting reduced-risk drinking. Presented at the 2011 NEI Global Psychopharmacology Congress.
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